In addition to the core symptoms of depression, atypical depression is defined by the ability to feel better temporarily in response to a positive life event, plus any two of the following criteria: excessive sleep, overeating, a feeling of heaviness in the limbs and a sensitivity to rejection.
Patients with atypical depression tend to have an earlier age of onset than those with other subtypes (it often first appears in the teenage years). These patients are also likely to have a history of social phobia, avoidant personalities and a history of body dysmorphic disorder.1
How Common Is Atypical Depression?
Despite the name, atypical depression is actually the most common subtype, according to Dr. Andrew A. Nierenberg, associate director of the depression clinical and research program at Massachusetts General Hospital, Boston. In a 1998 study, he and his associates found that 42% of participants had atypical depression, 12% had melancholic depression, 14% had both depression subtypes, and the rest had neither. "It's more common than we all think. There's no doubt we underrecognize it,"said Dr. Nierenberg.2
Making a correct diagnosis of this subtype is critical in providing the patient with effective treatment. Although SSRIs and other newer medications are often the first line choice for depression treatment due to their favorable side-effect profiles, very little is yet known about how well these work for the patient with atypical depression. What is known is that patients respond well to MAOIs, but not to tricyclics. Data on newer medications is sparse and inconclusive.3 How many patients out there may be suffering through drug trial after drug trial simply because their physician does not know which medication best treats atypical depressions or does not recognize this distinct subtype?
How Is Atypical Depression Treated?
Current data suggests that those with atypical depression will respond better to MAOIs (monoamine oxidase inhibitors) like phenelzine than they will to imipramine (a tricyclic). Dietary restrictions and side-effects remain a problem. At the present time, research is concentrating on finding newer medications with better side-effect profiles to which these patients will also get a good response.4
Although more research is needed, it seems that patients may also obtain an adequate response with the SSRIs, but not all studies seem to back up this assertion. In one study, the SSRI Prozac was found to have a response only equal to imipramine, a tricyclic whose comparative response to phenelzine is well-known.5
Interestingly, however, drug treatment may not be necessary at all. A study conducted in 1999 found that patients receiving cognitive behavioral therapy responded just as well as patients receiving the MAOI phenelzine. 58% of patients in both groups responded, in comparison to only 28% of patients in the placebo group.6
Implications for the Patient
It is important to see a psychiatrist rather than your primary care physician for treatment. Not all depressions are alike nor do they respond to the same medications. A physician in general practice is not likely to have the experience necessary to differentiate between subtypes of depression or to know which treatment choices are more likely to work. A patient may suffer unnecessarily as his doctor tries all the wrong medications. Given the very nature of depression, this only complicates the patient's already depressed feelings. If the patient is forced by insurance or financial circumstances to see a primary care physician for their treatment, they must do the leg work to make up the deficit in their physician's knowledge. This is not as it should be, certainly, but until there is a radical change in our healthcare systems, it is necessary. The educated healthcare consumer who takes an active role in his or her treatment is less likely to slip through the diagnostic cracks.
1. Clinical Psychiatry News 26(12):25, 1998.
4. Journal of Clinical Psychiatry 59 Suppl 18:5-9, 1998.
5. American Journal of Psychiatry 157(3):344-350, Mar 2000.
6. Archives of General Psychiatry 56(5):431-47, May 1999.